Who accepts nudges? nudge acceptability from a self-regulation perspective.

BACKGROUND: Public acceptability of nudging is receiving increasingly more attention, but studies remain limited to evaluations of aspects of the nudge itself or (inferred intentions) of the nudger. Yet, it is important to investigate which individuals are likely to accept nudges, as those who are supposed to benefit from the implementation should not oppose it. The main objective of this study was to integrate research on self-regulation and nudging, and to examine acceptability of nudges as a function of self-regulation capacity and motivation. METHOD: Participants (N = 301) filled in questionnaires about several components of self-regulation capacity (self-control, proactive coping competence, self-efficacy, perceived control and perceived difficulty) and motivation (autonomous motivation and controlled motivation). To evaluate nudge acceptability, we used three vignettes describing three types of nudges (default, portion size, and rearrangement) that stimulated either a pro-self behavior (healthy eating) or pro-social behavior (sustainable eating) and asked participants to rate the nudges on (aspects of) acceptability. RESULTS: Results revealed that there were substantial differences in acceptability between the three types of nudges, such that the default nudge was seen as less acceptable and the rearrangement nudge as most acceptable. The behavior that was stimulated did not affect acceptability, even though the nudges that targeted healthy eating were seen as more pro-self than the nudges targeting sustainable eating. From all self-regulation components, autonomous motivation was the only measure that was consistently associated with nudge acceptability across the three nudges. For self-regulatory capacity, only some elements were occasionally related to acceptability for some nudges. CONCLUSION: The current study thus shows that people are more inclined to accept nudges that target behaviors that they are autonomously motivated for, while people do not meaningfully base their judgments of acceptability on self-regulatory capacity.

Nudge strategies for behavior-based prevention and control of neglected tropical diseases: A scoping review and ethical assessment.

BACKGROUND: Nudging, a strategy that uses subtle stimuli to direct people's behavior, has recently been included as an effective and low-cost behavior change strategy in low- and middle- income countries (LMIC), targeting behavior-based prevention and control of neglected tropical diseases (NTDs). The present scoping review aims to provide a timely overview of how nudge interventions have been applied within this field. In addition, the review proposes a framework for the ethical consideration of nudges for NTD prevention and control, or more broadly global health promotion. METHODS: A comprehensive search was performed in several databases: MEDLINE, PsycINFO, and Embase (Ovid), Web of Science Core Collection, CINAHL, ERIC and Econ.Lit (EBSCO), as well as registered trials and reviews in CENTRAL and PROSPERO to identify ongoing or unpublished studies. Additionally, studies were included through a handpicked search on websites of governmental nudge units and global health or development organizations. RESULTS: This scoping review identified 33 relevant studies, with only two studies targeting NTDs in particular, resulting in a total of 67 nudge strategies. Most nudges targeted handwashing behavior and were focused on general health practices rather than targeting a specific disease. The most common nudge strategies were those targeting decision assistance, such as facilitating commitment and reminder actions. The majority of nudges were of moderate to high ethical standards, with the highest standards being those that had the most immediate and significant health benefits, and those implemented by agents in a trust relationship with the target audience. CONCLUSION: Three key recommendations should inform research investigating nudge strategies in global health promotion in general. Firstly, future efforts should investigate the different opportunities that nudges present for targeting NTDs in particular, rather than relying solely on integrated health promotion approaches. Secondly, to apply robust study designs including rigorous process and impact evaluation which allow for a better understanding of 'what works' and 'how it works'. Finally, to consider the ethical implications of implementing nudge strategies, specifically in LMIC.

Between a woman and her fetus: Bedouin women mediators advance the health of pregnant women and babies in their society.

INTRODUCTION: Bedouin women in Israel confront a challenging circumstance between their traditional patriarchal society and transition to modernity. In terms of reproductive health, they face grave disparities as women, pregnant women and mothers. In this article we aim to understand the challenges of Bedouin women who work as mediators in the promotion of Bedouin women's perinatal health. We explore their challenges with the dual and often conflictual role as health peer-instructors-mediators in mother-and-child clinics, and also as members of a Bedouin community, embodying a status as women, mothers, and family caretakers. Drawn upon a feminist interpretative framework, the article describes their challenges in matters of perinatal health. Our research question is: how do women who traditionally suffer from blatant gender inequality utilize health-promotion work to navigate and empower themselves and other Bedouin women. METHODS: Based on an interpretive feminist framework, we performed narrative analysis on eleven in-depth interviews with health mediators who worked in a project in the Negev area of Israel. The article qualitatively analyses the ways in which Bedouin women mediators narrate their challenging situations. RESULTS: This article shows how difficult health mediators' task may be for women with restricted education who struggle for autonomy and better social and maternal status. Through their praxis, women mediators develop a critical perspective without risking their commitments as women who are committed to their work as well as their society, communities, and families. These health mediators navigate their ways between the demands of their employer (the Israeli national mother and child health services) and their patriarchal Bedouin society. While avoiding open conflictual confrontations with both hegemonic powers, they also develop self-confidence and a critical and active approach. CONCLUSIONS: The article shows the ways by which the mediator's activity involved in perinatal health-promotion may utilize modern perinatal medical knowledge to increase women's awareness and autonomy over their pregnant bodies and their role as caregivers. We hope our results will be applicable for other women as well, especially for women who belong to other traditional and patriarchal societies.

Ethics of sharing medical knowledge with the community: is the physician responsible for medical outreach during a pandemic?

A recent update to the Geneva Declaration's 'Physician Pledge' involves the ethical requirement of physicians to share medical knowledge for the benefit of patients and healthcare. With the spread of COVID-19, pockets exist in every country with different viral expressions. In the Chareidi ('ultra-orthodox') religious community, for example, rates of COVID-19 transmission and dissemination are above average compared with other communities within the same countries. While viral spread in densely populated communities is common during pandemics, several reasons have been suggested to explain the blatant flouting of public health regulations. It is easy to fault the Chareidi population for their proliferation of COVID-19, partly due to their avoidance of social media and internet aversion. However, the question remains: who is to blame for their community crisis? The ethical argument suggests that from a public health perspective, the physician needs to reach out and share medical knowledge with the community. The public's best interests are critical in a pandemic and should supersede any considerations of cultural differences. By all indications, therefore, the physician has an ethical obligation to promote population healthcare and share medical knowledge based on ethical concepts of beneficence, non-maleficence, utilitarian ethics as well as social, procedural and distributive justice. This includes the ethical duty to reduce health disparities and convey the message that individual responsibility for health has repercussions within the context of broader social accountability. Creative channels are clearly demanded for this ethical challenge, including measured medical paternalism with appropriate cultural sensitivity in physician community outreach.

The moral perils of conditional cash transfer programmes and their significance for policy: a meta-ethnography of the ethical debate.

Conditional cash transfer (CCT) is a compelling policy alternative for reducing poverty and improving health, and its effectiveness is promising. CCT programmes have been widely deployed across geographical, economic and political contexts, but not without contestation. Critics argue that CCTs may result in infringements on freedom and dignity, gender discrimination and disempowerment and power imbalances between programme providers and beneficiaries. In this analysis, we aim to identify the ethical concepts applicable to CCTs and to contextualize these by mapping the tensions of the debate, allowing us to understand the separate contributions as parts of a larger whole. We searched a range of databases for records on public health CCT. Strategies were last run in January 2017. We included 31 dialectical articles deliberating the ethics of CCTs and applied a meta-ethnographic approach. We identified 22 distinct ethical concepts. By analysing and mapping the tensions in the discourse, the following four strands of debate emerged: (1) responsibility for poverty and health: personal vs public duty, (2) power balance: autonomy vs paternalism, (3) social justice: empowerment vs oppression and (4) marketization of human behaviour and health: 'fair trade' vs moral corruption. The debate shed light on the ethical ideals, principles and doctrines underpinning CCT. These were consistent with a market-oriented liberal welfare regime ideal: privatization of public responsibilities; a selective rather than a universal approach; empowerment by individual entrepreneurship; marketization of health with a conception of human beings as utility maximizing creatures; and limited acknowledgement of the role of structural injustices in poverty and health. Identification of key tensions in the public health ethics debate may expose underpinning ideological logics of health and social programmes that may be at odds with public values and contemporary political priorities. Decisions about CCTs should therefore not be considered a technical exercise, but a context-dependent process requiring transparent, informed and deliberative decision-making.

Does Health Promotion Harm the Environment?

Health promotion involves social and environmental interventions designed to benefit and protect health. It often harmfully impacts the environment through air and water pollution, medical waste, greenhouse gas emissions, and other externalities. We consider potential conflicts between health promotion and environmental protection and why and how the healthcare industry might promote health while protecting environments. After probing conflicts between promoting health and protecting the environment we highlight the essential role that environmental resources play in health and healthcare to show that environmental protection is a form of health promotion. We then explore relationships between three radical forms of health promotion and the environment: (1) lowering the human birth rate; (2) transforming the food system; and (3) genetically modifying mosquitos. We conclude that healthcare and other industries and their institutions and leaders have responsibilities to re-consider and modify their priorities, policies, and practices.

Promoting male circumcision as HIV prevention in sub-Saharan Africa: An evaluation of the ethical and pragmatic considerations of adopting a demand creation approach.

Male circumcision for HIV prevention is being promoted in 14 sub-Saharan African countries. Campaigns take a demand creation approach, a strategy based on generating awareness of and demand for an intervention. This article analyzes campaign materials, making the case that a focus on demand per se, at the expense of quality public health information, constitutes an ethical and pragmatic campaign flaw. Clinical trials have demonstrated that circumcision can reduce transmission of HIV from women to men by 53-60%. Since circumcision does not approach 100% prevention efficacy for men and does not directly protect women, behavioural and structural interventions remain necessary, leading international health bodies to position circumcision as an add-on to behavioural interventions. However, in practice, circumcision promotion often lacks information about behavioural prevention. At times, campaigns omit any HIV prevention message. Instead, campaigns variously favour representing circumcision as a route to normative masculinity, to sexual prowess, or to good citizenship, among others. Alongside their targeted outcomes, public health campaigns also contribute to public discourses around sexuality and non-HIV aspects of health, in this case potentially leading to confusion and mistrust. The current public health promotion strategy for circumcision threatens to undermine the social processes needed to support HIV prevention.

On Knowingly Setting Unrealistic Goals in Public Health.

What is the ethics of setting unrealistic goals in public health-declared goals of population health campaigns that, when introduced, are already known to be impossible to accomplish? Over the past 2 decades, major public health campaigns have set unrealistic goals, such as "eliminating" or reaching "zero" on diseases and risk factors that are clearly ineliminable.We argue that unrealistic goals can sometimes motivate action, attract funding, and help educate the public and public health practitioners better than realistic goals. Although unrealistic goal setting faces ethical challenges, including the charge of deceit and that of undermining the field's credibility, we argue that these challenges can be met.The advantages of unrealistic goal setting while overcoming these challenges can be accomplished in 2 stages: (1) an initial declaration of the attractive but unrealistic goal educates and motivates; (2) realistic, precise, and actionable subgoals then expose its unrealistic nature and preempt ongoing deceit.

Incentives for Smoking Cessation During Pregnancy: An Ethical Framework.

INTRODUCTION: Smoking during pregnancy increases the risk of morbidity and mortality of the mother and child. The inability of the unborn child to protect itself, raises the social and academic responsibility to protect the child from the harmful effects of smoking. Interventions including rewards (incentives) for lifestyle changes are an upcoming trend and can encourage women to quit smoking. However, these incentives can, as we will argue, also have negative consequences, for example the restriction of personal autonomy and encouragement of smoking to become eligible for participation. To prevent these negative consequences, we developed an ethical framework that enables to assess and address unwanted consequences of incentive-based interventions whereby moral permissibility can be evaluated. AIMS AND METHODS: The possible adverse consequences of incentives were identified through an extensive literature search. Subsequently, we developed ethical criteria to identify these consequences based on the biomedical ethical principles of Beauchamp and Childress. RESULTS: Our framework consists of 12 criteria. These criteria concern (1) effectiveness, (2) support of a healthy lifestyle, (3) motivational for the target population, (4) stimulating unhealthy behavior, (5) negative attitudes, (6) personal autonomy, (7) intrinsic motivation, (8) privacy, (9) fairness, (10) allocation of incentives, (11) cost-effectiveness, and (12) health inequity. Based on these criteria, the moral permissibility of potential interventions can be evaluated. CONCLUSIONS: Incentives for smoking cessation are a response to the responsibility to protect the unborn child. But these interventions might have possible adverse effects. This ethical framework aims to identify and address ethical pitfalls in order to avoid these adverse effects. IMPLICATIONS: Although various interventions to promote smoking cessation during pregnancy exist, many women still smoke during pregnancy. Interventions using incentives for smoking cessation during pregnancy are a promising and upcoming trend but can have unwanted consequences. This ethical framework helps to identify and address ethical pitfalls in order to avoid these adverse effects.It can be a practical tool in the development and evaluation of these interventions and in evaluating the moral permissibility of interventions using incentives for smoking cessation during pregnancy.

Building the case for actionable ethics in digital health research supported by artificial intelligence.

The digital revolution is disrupting the ways in which health research is conducted, and subsequently, changing healthcare. Direct-to-consumer wellness products and mobile apps, pervasive sensor technologies and access to social network data offer exciting opportunities for researchers to passively observe and/or track patients 'in the wild' and 24/7. The volume of granular personal health data gathered using these technologies is unprecedented, and is increasingly leveraged to inform personalized health promotion and disease treatment interventions. The use of artificial intelligence in the health sector is also increasing. Although rich with potential, the digital health ecosystem presents new ethical challenges for those making decisions about the selection, testing, implementation and evaluation of technologies for use in healthcare. As the 'Wild West' of digital health research unfolds, it is important to recognize who is involved, and identify how each party can and should take responsibility to advance the ethical practices of this work. While not a comprehensive review, we describe the landscape, identify gaps to be addressed, and offer recommendations as to how stakeholders can and should take responsibility to advance socially responsible digital health research.

Responsibility in healthcare across time and agents.

It is unclear whether someone's responsibility for developing a disease or maintaining his or her health should affect what healthcare he or she receives. While this dispute continues, we suggest that, if responsibility is to play a role in healthcare, the concept must be rethought in order to reflect the sense in which many health-related behaviours occur repeatedly over time and are the product of more than one agent. Most philosophical accounts of responsibility are synchronic and individualistic; we indicate here what paying more attention to the diachronic and dyadic aspects of responsibility might involve and what implications this could have for assessments of responsibility for health-related behaviour.

Ethical Criteria for Health-Promoting Nudges: A Case-by-Case Analysis.

Health-promoting nudges have been put into practice by different agents, in different contexts and with different aims. This article formulates a set of criteria that enables a thorough ethical evaluation of such nudges. As such, it bridges the gap between the abstract, theoretical debates among academics and the actual behavioral interventions being implemented in practice. The criteria are derived from arguments against nudges, which allegedly disrespect nudgees, as these would impose values on nudgees and/or violate their rationality and autonomy. Instead of interpreting these objections as knock-down arguments, I take them as expressing legitimate worries that can often be addressed. I analyze six prototypical nudge cases, such as Google's rearrangement of fridges and the use of defaults in organ donation registration. I show how the ethical criteria listed are satisfied by most-but not all-nudges in most-but not all-circumstances.

The Role of Physicians in the Allocation of Health Care: Is Some Justice Better than None?

Physicians' advocacy obligations are best understood as going beyond advocacy on behalf of individual patients, which I call the "individualistic view," to include advocacy for intelligent research-based allocation schemes that promote good outcomes and cost-effective care for all patients, which I call the "systemic view." This systemic view includes moving beyond self-interest to promote less-wasteful and more cost-conscious allocation decisions and the setting of priorities at all levels to expand health care access. It includes physician involvement in discussions with patients in the context of clinical care, involvement in the formulation and administration of benefit structures and other allocation policies, and, finally, involvement in promoting public dialogue about health care priorities. This involvement is based on a concept of a deliberative process that can result in "just enough" decisions within systems for the preservation and promotion of health care and other societal goods.

The oral biome in the aetiology and management of dental disease: Current concepts and ethical considerations.

Our understanding of the complexity of the oral biome and of the role of the various constituent bacteria in the aetiology of dental disease is growing. Probiotics and their relationship with prebiotics, as well as other microbiome-based interventions, could be useful in preventing and treating dental disease and in promoting oral health. However, given the promise and early stage of this treatment approach, there are also a number of ethical, social and regulatory issues associated with innovative probiotic therapy. In this article, a brief update is given on contemporary theories of the aetiology and management of the two commonest dental diseases, and on the roles of pre- and probiotics and oral biome transplant in the management of these diseases. The focus is primarily on four core issues: informed consent, risk-benefit assessment, how to determine suitable healthy donors, and commercialization and regulation. We discuss the safety and benefits of oral probiotics, not only concerning the products and quality control during their manufacture, but also regarding the depth of public knowledge about this topic. We point out that the requirement of listing ingredients honestly might be insufficient, and that the prevalent rhetoric of 'natural' and 'organic' as well as some health claims in the translational, innovative probiotic industry and markets are themselves misleading and should be carefully scrutinized. Finally, we suggest an ethical imperative to find a balance between scientific research and industry, and public health in the regulation of probiotics.

AMA Policies and Code of Medical Ethics' Opinions Related to Health Promotion and Community Development.

Physicians play important roles in community development. They seek not only to increase patients' overall well-being and the quality of care in clinical settings, but also to engage communities in health promotion and public health efforts. The AMA Code of Medical Ethics offers guidance to physicians developing community health initiatives, especially regarding health promotion, community development, and rural health care access.

Benefits and harms of wellness initiatives.

Wellness projects are large scale studies of healthy individuals through extensive laboratory and other testing. The "Hundred Person Wellness Study", was one of the first to report results and lessons from its approach and these lessons can be applied to other wellness projects which are being undertaken by major companies and other organizations. In the "Hundred Person Wellness Study", investigators from the Institute for Systems Biology (ISB) sequenced the genome, and analyzed the blood, saliva, urine and microbiome of 108 healthy participants every 3 months, for 9 months, to look for subtle changes signifying the transition to disease. We discuss some of the possible shortcomings of this approach; questioning the need to "improve" biomarker levels, excessive testing leading to over-diagnosis and over-treatment, expected results and improvements, selection of tests, problems with whole genome sequencing and speculations on therapeutic measures. We hope this discussion will lead to a continued evaluation of wellness interventions, leading to strategies that truly benefit patients within the constraint of limited health care resources.

Ethical considerations for the design and implementation of child injury prevention interventions: the example of delivering and installing safety equipment into the home.

INTRODUCTION: Public health ethics is a growing field of academic interest but ethical discussion of injury prevention seems to have received limited attention. Interventions that promise to be effective are not necessarily-without explicit justification-'good' and 'right' interventions in every sense. This paper explores public health ethics in the context of child injury prevention with the objective to initiate interdisciplinary dialogue on the ethics of child safety interventions. METHOD: A framework of seven public health ethics principles (non-maleficence, health maximisation, beneficence, respect for autonomy, justice, efficiency and proportionality) were applied to an intervention to promote child safety in the home. RESULTS: Preventing child injury in the home is ethically challenging due to the requirement for the state to intervene in the private sphere. Non-maleficence and beneficence are difficult to judge within this intervention as these are likely to be highly dependent on the nature of intervention delivery, in particular, the quality of communication. Respect for autonomy is challenged by an intervention occurring in the home. The socioeconomic gradient in child injury risk is an important factor but a nuanced approach could help to avoid exacerbating inequalities or stigmatisation. Equally, a nuanced approach may be necessary to accommodate the principles of proportionality and efficiency within the local context. CONCLUSION: We conclude that this intervention is justifiable from an ethical perspective but that this type of reflection loop is helpful to identify the impact of interventions beyond effectiveness.

How to distinguish medicalization from over-medicalization?

Is medicalization always harmful? When does medicine overstep its proper boundaries? The aim of this article is to outline the pragmatic criteria for distinguishing between medicalization and over-medicalization. The consequences of considering a phenomenon to be a medical problem may take radically different forms depending on whether the problem in question is correctly or incorrectly perceived as a medical issue. Neither indiscriminate acceptance of medicalization of subsequent areas of human existence, nor criticizing new medicalization cases just because they are medicalization can be justified. The article: (i) identifies various consequences of both well-founded medicalization and over-medicalization; (ii) demonstrates that the issue of defining appropriate limits of medicine cannot be solved by creating an optimum model of health; (iii) proposes four guiding questions to help distinguish medicalization from over-medicalization. The article should foster a normative analysis of the phenomenon of medicalization and contribute to the bioethical reflection on the boundaries of medicine.